Printed name:

DOB:

Adress:

Phone number:

Our Notice of Privacy Practices provides information about how we may use and diclose protected health information (PHI) about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA).
Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. If terms of our Notice change, a revised copy will be made available to you.

By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, or payment or healthcare operations.

Please write your signature in the box below(required)

Clear

Date:

Printed Name of Patient:

Legal Relationship to the Patient (if required:

I give you permission to share my health information with:

Name:

Relationship

Phone:

Name:

Relationship

Phone:

If you approve, we may contact you via email and/or text messaging to remind you of an appointment or provide general health reminders or information. I understand that once i have consented to receive communications via text or email, i still have the right to revoke the consent at any time.

The cell phone number i authorize to receive text messeges for appointment reminders and general health information is:

Cell phone:

Please initial:

The email address that i authorize to receive text messeges for appointment reminders and general health information is:

Email Address:

Please initial:

I decline to receive communication via text.I decline to receive communication via email.